Henry G. Schwartz

Prognostic factors and results of surgery and postoperative irradiation in the management of pituitary adenomas.

Prognostic factors and results of therapy were analyzed in a retrospective examination of 121 patients with pituitary adenomas treated with surgery and postoperative irradiation (RT) from January 1954 through December 1982 at the Radiation Oncology Center, Mallinckrodt Institute of Radiology. The 10-year overall and disease-free survival for all patients was 85.1 and 89.4%. The expected survival for an age-, gender-, and race-matched population was not significantly distinct at 85.3% (p = 0.72). Follow-up of 94 surviving patients ranged from 3.4 to 29.5 years (mean, 11.7). Statistical analysis was performed for multiple prognostic factors including age, race, gender, disease bulk, visual field symptoms, disease type, surgical approach, and irradiation dose and volume. The only prognostic variable identified by univariate analysis to significantly alter disease-free survival was irradiation dose. Patients receiving 5000-5400 cGy had a tumor control rate of 94.1% (64/68) compared to 85.0% (17/20) for 4000-4999 cGy, 75.0% (18/24) for 3000-3999 cGy, and 28.6% (2/7) for less than 3000 cGy (p = 0.000059). Factors evaluated but established to be insignificant were age, race, gender, disease bulk, visual field symptoms, disease type, surgical approach, and irradiated volume. The 10-year disease-free survival by classification was 93.3% for patients with amenorrhea/galactorrhea, 89.9% for non-functioning adenomas, and 76.4% for acromegaly (p = 0.21). Overall improvement in visual field defects subsequent to treatment occurred in 48.4% (44/91) of those with visual field defects before RT and was significantly correlated with RT dose. The median time to progression of disease was 10.2 years with the last failure occurring at 25 years following the fulfillment of RT. Severe complications related to RT were apparent in 1.7% (2/121). None were known to have endured brain radionecrosis. Serious surgical complications occurred in 9.9% (12/121).

Irradiation of primary thalamic and brainstem tumors in a pediatric population. A 33-year experience.

A retrospective analysis of 70 pediatric patients (<16 years of age) with histologically proven or presumed primary neoplasms of the thalamus, hypothalamus, and brainstem, treated with combined surgery and postoperative radiotherapy or radiotherapy alone at the Washington University Medical Center from January 1950 through December 1983, is reported. Overall survival for all patients at 5 and 10 years was 34.9% and 32.7%, respectively. Follow‐up of the 22 surviving patients ranged from 3.0 to 20.0 years (median, 10.6 years). Statistical analysis of multiple prognostic factors was performed. Prognostic factors found by single variate analysis to significantly influence survival were primary site of disease, extent of surgery, race, cranial nerve paresis at diagnosis, and dose of radiation. Factors evaluated but found to be insignificant were age at diagnosis, duration of symptoms before diagnosis, sex, and volume irradiated. Multivariate analysis revealed that only total radiation dose and race were of prognostic significance.

Multivariate analysis of prognostic factors in pediatric and adult thalamic and brainstem tumors

A multivariate analysis of prognostic variables was performed on a retrospective review of 136 patients with presumed or histologically proven primary lesions of the thalamus and brainstem treated by combined surgery and post-operative irradiation or by irradiation alone from January 1950 through December 1983. Overall survival for all patients at 5 and 10 years was 34.4 and 27.8%, respectively. Follow-up of 33 living patients ranged from 3 to 22 years. Prognostic variables analyzed by univariate analysis and found to be of significance (p less than 0.05) were race, duration of symptoms, extent of surgery (i.e. subtotal excision), and dose of irradiation. Further evaluation by Cox regression analysis revealed these same factors to be of prognostic significance (p less than 0.05). It is of importance to note that age and tumor site were not significant prognostic variables in the multivariate analysis but were significant by univariate analysis. The 5-year overall survival for patients with thalamic tumors was 59.5 and 20.9% for children and adults, respectively (p = 0.006). The 5-year overall survival for patients with pontine lesions was 46.6 and 16.0% for adults and children, respectively (p = 0.01). Only one patient was known to have expired due to a complication of therapy. Neurologic deficits and functional ability was normal or mild in 57.6% of the surviving patients.

Prognostic factors and results of therapy for adult thalamic and brainstem tumors

This report is a retrospective analysis of 83 adults (>16 years of age) with histologically proven or presumed primary neoplasms of the thalamus, hypothalamus, midbrain, pons, and medulla. Patients were treated with combined surgery and postoperative irradiation or with irradiation alone at the Washington University Medical Center (St. Louis, MO) from January 1950 through December 1984. Histologic analysis confirmed the diagnosis of tumor in 21, including nine with well‐differentiated astrocytoma, four with astrocytoma with anaplasia, and eight with glioblastoma multiforme. Overall and disease‐free survivals at 5 years were 28.7 and 23.2%, respectively. A statistical analysis was performed to ascertain the prognostic importance of the following variables: age, race, gender, duration of symptoms, cranial nerve paresis, primary site, extent of surgery, histology, and irradiation dose. The only factor identified by univariate analysis to be critical for survival was primary location of disease. Patients with supratentorial (thalamus/ hypothalamus, midbrain) tumors had a 10‐year disease‐free survival of 15.4% compared to 29.6% for those with infratentorial (pons, medulla) tumors (P = 0.07). Patients with lesions of the pons had a 5‐year disease‐free survival of 35.8% compared to 13.8% for those with tumors of the thalamus (P = 0.05). Increasing irradiation dose was not correlated with superior survival. Factors evaluated but established to be insignificant were age (P = 0.27), race (P = 0.63), gender (P = 0.27), duration of symptoms (P = 0.19), cranial nerve paresis (P = 0.71), histologic type (P = 0.16), and extent of surgery (P = 0.94). Follow‐up for 13 surviving patients ranged from 2.6 to 28.7 (mean, 12.0) years. Neurologic deficits in surviving patients were absent in 15% (two of 13), mild in 62% (eight of 23), and moderate in 23% (three of 13). One case of brain radionecrosis was identified (6000 cGy, 200 cGy daily).

Effect of Sorbitol and Sucrose on Cerebrospinal Fluid Pressure and Urine Output

Summary Parallel experiments have been carried out on 9 pairs of dogs. 50% sorbitol, in a dosage of 2.5 cc/kg, injected intravenously at a rate of 7 cc/min causes a more marked and protracted fall in cerebrospinal fluid pressure, and a greater diuresis, than does an equivalent amount of sucrose.

Ruptured Cervical Intervertebral Disks

Lateral rupture of the cervical intervertebral disks should be considered in the differential diagnosis in a patient with a history of pain or stiffness of the neck, with radiation of pain to the shoulder, arm or hand. In some cases the superficial impression may be that of angina pectoris. Differential diagnosis between cervical rib and scalenus anticus syndrome and cervical disk can usually be made on the basis of the point of reference of pain or numbness. In cases of cervical disk rupture, symptoms and signs are usually referable to the sixth and seventh cervical dermatomes, whereas the other conditions usually involve the eighth dermatome. Roentgenograms of the cervical spine frequently show reversal of the normal curve and narrowing of the suspected interspace.Cervical disks which rupture closer to the midline may produce signs and symptoms of degenerative cord disease, such as amyotrophic lateral sclerosis, or may even cause complete paralysis simulating spinal cord tumor.Because of the great risk ...

VIII. Training, Education, Manpower, and Research for Stroke Care

The manpower required for diagnosis and management of the 500,000 patients who experience stroke in the United States annually encompasses numerous disciplines, beginning with the family physician. The medical specialists and allied health personnel chiefly involved in addition are the neurologist, internist/cardiologist, nurse, physiatrist, physical therapist, occupational therapist, and speech therapist. Besides these, services of the radiologist, neurosurgeon, vascular surgeon, psychiatrist, orthopaedist, urologist, ophthalmologist, and pathologist frequently are needed. Important support is given by the dietitian, social worker, psychologist, and vocational rehabilitation counselor. Statistics are included for manpower available at present in a number of these disciplines. Training and education extend throughout all levels, from the undergraduate through the postgraduate, and including continuing education. The knowledge and skills which each of these special groups should possess for competence in the area of stroke are described. The results of a survey are summarized, indicating the current status of stroke care in the curricula of United States medical schools and schools of osteopathy. The concept of a stroke team is presented, describing the advantages of interdisciplinary action and effective utilization of available personnel and resources for patient care and for educational and training functions. An example is cited to demonstrate its feasibility and to illustrate the methods of establishing a local stroke program. The list of research needs in the area of stroke is extensive—over 100 pertinent topics are cited. Recommendations of the study group are summarized.